HomeMy WebLinkAboutApp-Permit-Compliance?-00te--� `I 66��G�.. FEE 110.00
V V COMMONWEALTH 01F MASSACHUSETTSC/,��,/
Board of Health, , , MA.
APPLICATION F®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT -'
Application for a Permit to Construct( Repai ,Z%,)/U ad Abandon( __rCogVteS3Aem ❑Individual Components
Location +
Owner's Name
Can eelTt
Map/Parcel# & ,
Address `rt/
�%td e e-AbA - W V,2 rav)LA
Lot#
Telephone#
Installer's Name PACOj
Designer's Name
Address I_E Q
Address g
n
Telephone# ..,V$
Telephone#
520
Type of Building I aQ.1)-�i12 Lot Size 46.� 00d sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ,/10 gpd Calculated design flow Design flow provided 2_114& gpd
Plan: Date oi_2hp / 7 Number of sheets -3 Revision Date
Title
Description of Soil (s) (_1QSS
Soil Evaluator Form No. 56_*� q% Name of Soil Evaluator,. 66 /) Zi1Ve S Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
d /
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to'not to the system inperation until a Certificate of Compliance has been issued by the Board of Health.
Signed �: f' l Date
Inspections 2 ,,C
No.���E:i'tl
COMMONWEALTH OF MASSACHUSETTS
.7- 2 Board of Health, km4 -4M.
CERTIFICATE Of COMPLIANCE �
Description of Work: ❑ Individual Component(s) a°Complefjee,fiystepi
The undersigned hereby certify that the Sewage Disposal System; 6C!! oii)d-'�ctid Repaired ( ), Upgraded ( ), Abandoned ( )
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Na dated 7 Approved Design Flow (gpd)
Installer
Designer: Qry �Q &a/,30er.� Inspector: �/' � Date: r
Toe
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No° '-�� ., y _. j�.°� FEET . Ci
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �P eN G i MA , MA.
DISPOSAL SYSTEM CONSTRUCTION PL'RMIT
Permission is�hereby granted to; Construct
nonstruct( Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system
t
at 440 .!q ('J-) f C_C f i�ei�i1, as described in the application for
Disposal System Construction Permit No. , dated S-/--,- 7.
Provided: Construction shall be completed with ar wsm the date of this pe mit. All local conditions must be met.
Form 1255 Rev.. 5/96 A.M. Sulkin Co. Chadeslown, MA Date P' f " Board of Health
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